Expression of Programmed Death Receptor 1 (PD-1) Gene and Its Ligand (PD-L1) in Patients with Laryngeal Cancer

(1) Background: The interaction of the programmed death receptor (PD-1) with its ligand 1 (PD-L1) allows cancer cells to escape from the control of the immune system. Research evaluating the expression of immune checkpoint genes in the tissues of laryngeal tumors may contribute to the introduction of new effective immunotherapeutic methods in this group of neoplasms. The aim of this study was to evaluate the expression of the gene for the programmed death receptor (PD-1) and its ligand (PD-L1) in laryngeal tumors (T1, T2, T3) in patients without lymph node involvement and distant metastases. (2) Methods: The study included 73 patients: 39 of them were diagnosed with carcinoma planoepiteliale keratodes (study group) and 34 with nasal septal deviation undergoing septoplasty (control group). Biological material for molecular tests (Real time PCR) was collected during surgical procedures. Furthermore, all study participants completed a questionnaire regarding, among others, smoking and body weight. (3) Results: Gene expression for programmed death receptor 1 (PD-1) and its ligand 1 (PD-L1) was, statistically, significantly higher (p < 0.0001) in tumor tissue than in unchanged mucosa. Moreover, it was found that the greater the tumor size, the higher the expression level of the tested molecules. (4) Conclusions: Although further research on the role of the PD-1/PD-L1 pathway in laryngeal tumors is necessary, the presented reports are promising and may constitute a contribution to considerations on the introduction of targeted immunotherapy with anti-PD1 and anti-PD-L1 monoclonal antibodies in the treatment of these tumors.

Composite tumor of the larynx: A Case Report

Composite tumor of larynx, a recently included entity in the current WHO classification, is often a difficult pathological diagnosis, especially in small biopsies. We report a case of laryngeal composite tumor, initially misdiagnosed as squamous cell carcinoma, which later turned out to be composite in nature, with associated neuroendocrine (small cell carcinoma) component. This report emphasizes the need for obtaining deeper biopsies and their thorough pathological examination to improve the diagnostic accuracy. 

Passive wideband concentric rings resonator for vocal cords abnormalities detection: Application on larynx cancer pathologies

This work addresses the study and design of a diagnostic device consisting of a thin-film sensor array based on 8-mm concentered rings, acting as an autonomous acoustic sensor covering a wide range of resonance frequencies (0.1 KHz-2 MHz). In addition to its advantageous shape, this device integrates both the active vibratory element and the embedded electronics dedicated to coding, control, and analysis. The results show that the experimental device could be the basis of a telemedical platform for the objective assessment and monitoring of chronic laryngeal dysphonia through the spectro-temporal analysis of the vibration of the vocal cords. Furthermore, this non-invasive, non-intrusive protocol does not require the physical cooperation of the patient.

Adenoid cystic carcinoma in ventricle of larynx: An interesting case

RATIONALE

Adenoid cystic carcinomas (ACCs) are malignant tumors and occur in the major and the minor salivary glands. ACCs are rare in the larynx.

PATIENT CONCERNS

A 55-year-old female patient who presented with a 12 months history of paraesthesia pharynges and hoarseness for 4 months. Laryngoscopy showed an endophytic lesion in the right supglottic area with no laryngeal stenosis. And magnetic resonance imaging (MRI) confirmed the presence of a submucosal mass in the supglottic area. Supporting laryngoscope was performed under general anesthesia and a lesion biopsy obtained.

DIAGNOSES

The lesion was sent for frozen-section biopsy, which shows the lesion was the epithelial-derived tumors of salivary gland, but it was impossible to identify the relationship between the tumor and the surrounding normal tissue, and to judge the nature of the tumor further. So, the lesion was sent for the second frozen-section biopsy, an ACC of the larynx was confirmed and margins were negative.

INTERVENTIONS

The patient underwent partial laryngectomy.

OUTCOMES

The patient was doing well except hoarseness during the follow-up period with no evidence of disease recurrence or metastasis for 17 months post-operatively.

LESSONS

Laryngeal ACC is a rare entity. When the nature of lesion cannot be confirmed, multiple biopsies may be required for confirm the diagnosis of pathology. It not only reduces patient's waiting time for surgery, but also define the diagnosis and surgical removal of lesion through a single anesthesia.

The Telomerase and Alternative Lengthening of Telomeres Mechanisms Regulate Laryngeal Cancer Cell Apoptosis via the PI3K/Akt Pathway

PURPOSE

To investigate the possible telomerase and alternative lengthening of telomeres (ALT) mechanisms influencing the apoptosis of laryngeal squamous cells.

MATERIALS AND METHODS

The effects of the telomerase mechanism were observed by knockdown of human telomerase reverse transcriptase (hTERT). The ALT mechanism was induced by silencing related genes including TRF2, RAD51, and NBS1. Effects of telomerase and ALT mechanisms on tumor development were confirmed by xenograft tumors model. Tumor cell apoptosis was investigated by flow cytometry and Hoechst staining. Caspase-3 activity assay and Western blot were performed to investigate the possible mechanisms.

RESULTS

After silencing ALT- and telomerase mechanism-related genes, Bax and Bcl-2 were increased, and nuclear factor (NF)-κB translocation and PI3K/Akt phosphorylation were inhibited.

CONCLUSIONS

The inhibition of telomere-related genes inhibited the growth of laryngeal squamous cell carcinoma by promoting cell apoptosis via the PI3K/Akt pathway.

Functional outcome after one-stage flap reconstruction of the hypopharynx following tumor ablation

The main objective of this study was to evaluate functional outcome in terms of food passage of the three different reconstruction techniques that are currently most often used for hypopharyngeal reconstruction in our institution. A retrospective observational database research was conducted of all patients that underwent hypopharyngeal reconstruction for carcinoma of the hypopharynx or larynx from 1992 until 2014 in the University Medical Center Groningen. The following techniques were most commonly used and therefore analyzed: the pedicled pectoralis major flap, the radial forearm free flap and the anterolateral thigh free flap. Our primary outcome food passage was measured after 1 year and classified in gastric tube fed, fluids, semisolid or solid. Complications were registered according to the Clavien Dindo classification in five different grades. Comorbidity was scored using the Adult Comorbidity Evaluation Index. 58 patients were included. 51 patients survived one year follow up, 25 % returned to a solid diet, 40 % returned to a semi-solid diet and 20 % remained feeding tube dependent. Overall flap success rate was 88 and 35 % developed a pharyngocutaneous fistula. Multivariable ordinal regression showed that reconstruction with free flaps, a near-circumferential surgical defect, a higher body mass index and no comorbidity showed significantly better functional outcomes in the food passage. For recipient site complications, both free flaps and a shorter surgery time resulted in less severe complications. This study shows that the use of free flaps is superior to the use of the pectoralis major flap, and that it should therefore be reserved as a second choice.

Comparison of Functional Outcomes after Endoscopic versus Open-Neck Supraglottic Laryngectomies

Objectives:

Endoscopic supraglottic laryngectomy (ESL) by carbon dioxide laser for selected T1-T3 supraglottic squamous cell carcinomas is a sound procedure with oncological results comparable to those obtained by open-neck supraglottic laryngectomy (ONSL). The aim of this study was to retrospectively evaluate functional outcomes after ESL in comparison with ONSL.

Methods:

We performed perceptual voice evaluation by GRBAS (grade, roughness, breathiness, asthenicity, strain), subjective analysis by Voice Handicap Index, objective analysis with the Multidimensional Voice Program, swallowing evaluation with the M. D. Anderson Dysphagia Inventory, video nasal endoscopic examination of swallowing, videofluoroscopy, and analysis of hospitalization time, need for and duration of feeding tube and tracheotomy, and complication and aspiration pneumonia rates in a group of 14 patients treated with ESL. These results were compared to those obtained in a historical group of 14 patients matched for T category who were treated with ONSL at the same institution. Statistical analysis was performed with the Mann-Whitney U and Pearson χ2 tests.

Results:

Comparison of comprehensive voice analysis, M. D. Anderson Dysphagia Inventory, and complication and aspiration rates showed no statistically significant differences between the Two groups. However, significant differences were found for video nasal endoscopic examination of swallowing (p = .03), videofluoroscopy (p = .03), hospitalization (p = .0001), feeding tube duration (p = .0001), and tracheotomy duration (p = .0001).

Conclusions:

Endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than ONSL, even though it was not subjectively perceived by patients, and was associated with less morbidity and a shorter hospitalization time.

Vocal Efficiency Measurements in Subjects with Vocal Polyps and Nodules: A Preliminary Report

Vocal efficiency is a quantitative measure of the ability of the larynx to convert subglottal power to acoustic power. On the basis of the scant previous literature and clinical intuition, we tested the hypothesis that vocal efficiency, as an indicator of the functional status of the larynx, is abnormally reduced in persons with vocal nodules and polyps. Because the most difficult aspect of obtaining measures of vocal efficiency has been the determination of subglottal pressure, we applied a noninvasive airflow interruption technique for this purpose. Subjects with normal voices (n = 22), vocal polyps (n = 14), and vocal nodules (n = 16) phonated at different intensities into a mask connected by way of piping to a flow meter, a pressure transducer, and an acoustic microphone. Inflation of a balloon-type valve located within the piping provided interruption of phonation. The intraoral pressure plateau occurring during flow interruption was used to estimate subglottal pressure. Subglottal power and acoustic power were determined, and their quotient provided a measure of vocal efficiency. The vocal efficiency in the normal subjects averaged 1.15 × 10−5 at 70 dB, 3.17 × 10−5 at 75 dB, 7.52 × 10−5 at 80 dB, and 1.41 × 10−4 at 85 dB. The vocal efficiency in the patients with vocal polyps averaged 3.62 × 10−6 at 70 dB, 8.34 × 10−6 at 75 dB, 2.10 × 10−5 at 80 dB, and 4.26 × 10−5 at 85 dB. The vocal efficiency in the patients with vocal nodules averaged 4.32 × 10−6 at 70 dB, 1.57 × 10−5 at 75 dB, 4.26 × 10−5 at 80 dB, and 8.34 × 10−5 at 85 dB. As compared to the normal subjects, the patients with laryngeal polyps or vocal nodules had significantly reduced vocal efficiency. These results provide quantitative verification of the clinical impression of inefficient phonation in patients with mass lesions of the vocal folds.

[Effect of DJ-1 silencing by RNA interference on growth of xenografted human laryngeal squamous cell carcinoma Hep-2 cells in nude mice]

Objective: To investigate the effect of silencing DJ-1 on xenografted human laryngeal squamous cell carcinoma (LSCC) Hep-2 cells in nude mice. Methods: Xenograft model of human LSCC was established by subcutaneous transplantation of Hep-2 cells in 24 nude mice. The LSCC-bearing nude mice were randomly divided into 3 groups (n=8 in each):DJ-1 siRNA low dose group and DJ-1 siRNA high dose group were injected in tumors with 20 μg of DJ-1 siRNA or 40 μg of DJ-1 siRNA in 50 μL, respectively; control group was injected with 5% glucose solution in 50 μL, twice a week for 3 weeks. The weight and size of tumors were measured before injection. The animals were sacrificed 48 h after the final treatment, and the tumors were harvested and weighed. The apoptosis and proliferation of tumor cells were determined; the expressions of Caspase-3 and Ki-67 in tumor specimens were detected with immunohistochemistry. The expression of DJ-1, PTEN, survivin mRNA and protein in tumor tissues were detected by RT-PCR and Western blotting, respectively. Results: Tumor weight in low dose group[(0.66±0.15)g] and high dose group[(0.48±0.11)g] were significantly lower than that in control group[(0.83±0.16)g, all P<0.05]. The inhibition rates of low dose group and high dose group were (20.48±0.18)% and (42.16±0.13)%, respectively. Immunohistochemistry showed that the expression of Caspase-3 was increased and Ki-67 was reduced in tumor specimens, compared with the control group (all P<0.05). RT-PCR and Western blot results showed that in low dose group and high dose group the mRNA and protein expression of DJ-1 and survivin significantly decreased (all P<0.05), while PTEN mRNA and protein content increased (all P<0.05). Conclusion: High dose DJ-1 siRNA can inhibit the tumor growth in human LSCC xenograft nude mouse model, which indicates that down-regulating DJ-1 and survivin, and up-regulating PTEN expression may lead to blockage of PI3K-PKB/Akt signaling pathway and promoting tumor cell apoptosis.

A Preoperative Nutritional Index for Predicting Cancer-Specific and Overall Survival in Chinese Patients With Laryngeal Cancer: A Retrospective Study

Pinato prognostic nutritional index (PNI) adequately predicts long-term outcomes of various malignancies. However, its value in predicting outcomes in laryngeal squamous cell carcinoma (LSCC) is unknown. All patients newly diagnosed with LSCC presenting to the Department of Head and Neck Oncology at Sun Yat-sen University Cancer Center between January 1, 1990 and July 31, 2010 were eligible. The PNI was calculated as serum albumin (g/L) + 5 × total lymphocyte count/L. The Cutoff Finder software program was used to classify the patients into 3 groups for which the PNI score was at least 70% sensitive, at least 70% specific, or equivocal. Cancer-specific survival was estimated using the Kaplan-Meier method, and predictors were assessed with Cox regression analysis. Median time between surgery and PNI administration for the 975 eligible patients was 83 months. Index score groups were significantly associated with age, T stage, TNM stage, and type of surgery. Five-year CSS and OS were 57.3% and 56.6% in patients with PNI scores below 48.65 (low-probability of survival), 72.8% and 71.3% with scores between 48.65 and 56.93 (moderate-probability of survival), and 77.6% and 75.3% with scores above 56.93 (high-probability of survival); 10-year CSS and OS were 44.2% and 42.7%, 61.6% and 55.6%, 68.3% and 63.5%, respectively. The PNI score groups significantly predicted CSS and OS (P < 0.001). The PNI is an inexpensive and readily available score that predicted survival in patients with LSCC after curative laryngectomy.

Retrospective analysis of laser vs other therapeutic modalities for laryngeal papillomatosis: European multicenter study

PURPOSE

Laryngeal papillomatosis can be an aggressive and potentially life-threatening disease, affecting both children and adults. Local excision is the gold standard of treatment, but recurrences are frequently inevitable. The purpose of this study was to present the experience of three institutions with different therapeutic modalities and discuss them in relation with the relevant literature.

METHODS

Sixty patients underwent papilloma resection during the last decade in three institutions (Homburg/Saar and Marburg, Germany and Athens,Greece). Patient data were retrospectively analyzed for therapeutic modalities applied, rate of complications and synechia formation, necessary operations and need for tracheostomy.

RESULTS

Carbon dioxide laser therapy was the most common modality applied alone or combined with other treatment modalities. No major complication was observed, while glottic synechia was the most common minor complication in 5 (8.3%) patients. Of the patient cohort 55.6% required reoperation, while no patient required tracheostomy.

CONCLUSIONS

Surgical debulking with or without adjuvant treatment remains the mainstay of treatment, which mainly aims to reduce the number and frequency of recurrences since no definitive curative therapy is known so far.

[New Combination Therapy to Improve the Functional Preservation Rate of the Larynx in Laryngeal, Oropharyngeal, and Hypopharyngeal Cancers]

A new combination therapy has been developed to achieve high overall survival and functional laryngeal preservation rates in head and neck cancers, which require laryngectomy. In order to treat the primary site without resection, superselective intra-arterial infusions with DCF anterogradely and 60 mg/m2 of DOC and 60 mg/m2 of CDDP via the femoral artery on day 1 were administered, followed by continuous intravenous instillation of 750 mg/m2/day of 5-FU for 5 days from day 2. The 5- year survival rate was 70.4% in laryngeal cancer, 72.8% in oropharyngeal cancer, and 68.5% in hypopharyngeal cancer. The 5-year functional laryngeal preservation rate was 71.0% in laryngeal cancer, 63.4% in oropharyngeal cancer, and 65.2% in hypopharyngeal cancer. In addition to regional lymph node control, a thorough neck dissection was performed. Good overall survival and functional laryngeal preservation rates were achieved.

The effect of radiotherapy on mucociliary clearance in patients with laryngeal and nasopharyngeal cancer

The present study aimed to demonstrate how the nasal mucociliary transport times are affected in the patients receiving radiotherapy for head-neck tumor in two different anatomic localizations. The study included 44 patients receiving radiotherapy under the diagnoses of the nasopharyngeal and laryngeal cancer. The mucociliary transport times of both groups were measured via saccharine tablets before radiotherapy, and at months 3 and 6 after radiotherapy. The difference between the groups was statistically evaluated. The pre-irradiation (pre-RT) mean transport times of NPC and LC patients were 9.7 and 9.1 min, respectively. The difference in the mucociliary transport times between these two groups was not statistically significant (p = 0.49). The mean transport time was 26.1 min at post-RT month 3, 23.9 min, at month 6; the change from pre-RT to month 3 was significant (p < 0.05) and the change from month 3 to 6 was not statistically significant (p = 0.182). The mean transport time of the LC patients was 16.8 min. At post-RT month 3, 12.4 min. at month 6; the change from pre-RT to month 3 (p < 0.05) and the change from month 3 to 6 were statistically significant (p = 0.007). It was found that radiotherapy affected the physiological conditions of the patients with nasopharyngeal cancer in a more severe and sustained way compared to the LC patients, which negatively affects the patient's response to the treatment by the resulting organic and psychological effects.

What is the price of functional surgical organ preservation in local-regionally advanced supraglottic cancer? Long-term outcome for partial laryngectomy followed by radiotherapy in 32 patients

AIMS AND BACKGROUND

To achieve the goal of organ preservation, both a chemoradiotherapy and a conservative surgical approach can be proposed. The aim of the study was to review all patients treated in our Institute with conservative surgery and postoperative radiotherapy for locally advanced supraglottic tumor.

METHODS AND STUDY DESIGN

A retrospective analysis of 32 patients treated between 2000 and 2010 was performed. Overall survival, disease-free survival and late laryngeal toxicity were evaluated. The impact of surgical procedures, radiotherapy characteristics and addition of chemotherapy on late laryngeal toxicity was studied.

RESULTS

The median follow-up was 38 months. Overall survival and disease-free survival at 5 years were 73% and 66%, respectively. Three (9%) patients experienced local recurrence (after 22, 25 and 40 months, respectively) and were treated with total laryngectomy. The larynx preservation rate was 93%. Severe treatment-related late laryngeal toxicity (grade 3 and 4 laryngeal edema, laryngeal stenosis, presence of tracheotomy at last follow-up because of treatment-related toxicity, and the need for enteral nutrition) was experienced by 34% of patients. The functional larynx preservation rate was 81%. The statistically significant risk factors for severe late toxicity were: female gender, extension of the surgical procedure, removal of one arytenoid and association with concomitant chemotherapy.

CONCLUSIONS

We confirmed literature data on the feasibility and efficacy of a surgical organ preservation strategy. However, the high incidence of severe late toxicity requires further studies to improve patient selection and to reduce side effects.

Surgical treatment of T1b glottic tumor, 10-years follow-up

BACKGROUND

The TNM classification of glottic tumors defined T1b as a tumor involving both vocal cords with normal mobility of such. In the last fifteen years, in the medical literature, the role of open surgery for management of laringeal cancer has decreased considerably owing to the development of transoral laser microsurgery which is an oncologically and functionally reliable treatment particularly for early glottic cancers.

AIM

Report the efficacy of different surgical techniques (laser CO2 cordectomy or supracricoid partial laryngectomy) in T1b glottic cancers treatment with a 10-years follow-up.

PATIENTS AND METHODS

92 patients with T1b glottic cancer undergoing surgery between 1986 and 2002, of which 39 were treated with CO2 laser cordectomy while 53 with supracricoid partial laryngectomy (14 crico-hyoid-pexy and 39 crico-hyoid-epiglotto-pexy). Each of the three groups was recalled and evalued with the aim to calculate the survival, initially at 3 and 5 years and thereafter, provide a 10 years follow-up, including local recurrence.

RESULTS

10 years absolute survival of the 39 patient treated with CO2 laser was 56.25%, while that of the two groups subjected to supracricoid partial laryngectomy was respectively of 66.6% for crico-hyoid-pexy and 58.82% for crico-hyoid-epiglotto-pexy.

CONCLUSIONS

Our data suggest an excellent absolute survival also after 10 years follow-up. Since both the CO2 laser and supracricoid partial laryngectomy show similar local control and survival rates we can't determine with certainty the best therapeutic approach as claimed by a great number of literature studies.

Early evaluation of voice quality in glottic cancer (T1, T2) following curative radiotherapy

BACKGROUND

This is prospective study analyzing the subjective and objective quality of voice and voice related quality of life in patients of early glottic cancer (T1, T2 disease) before and after receiving curative radiotherapy.

METHODS

Fifteen patients of early glottic carcinoma (T1, T2) underwent voice assessment using multidimensional voice protocol based on recommendation by European Laryngological Society which included Perceptual analysis of voice by speech therapist and otolaryngologist, acoustic analysis; aerodynamic efficiency analysis-Maximum phonation time; patient's self perception of voice analysis--Voice handicap index; and videolaryngostroboscopy. Assessment was done prior to commencement of radiation therapy and at 1 month and 3 months following radio- therapy.

RESULTS

There was significant improvement in majority of the voice parameters post radiotherapy. Perceptual analysis showed significant improvement in GRBAS score following radiotherapy. Perturbation measures (jitter, shimmer, SNR, HNR) showed improvement post radiotherapy though remained inferior compared to controls. Mean fundamental frequency (Mean F0) and habitual frequency (habitual F0) decreased post radiotherapy. Intensity of voice increased following radiotherapy which was statistically significant (p < 0.05). There was significant improvement in the patient's perception of their quality of voice and voice related quality of life post radiotherapy. Maximum phonation time showed statistically significant improvement post-radiotherapy. Perceptual analysis of voice by professional observer correlated well with patients self perception of his own voice.

CONCLUSION

Voice quality improves following radiotherapy but not all the patients regain normal voice. Improvement in voice quality improves quality of life of patients shown by improved voice handicap index.

Endoplasmic reticulum stress is involved in the response of human laryngeal carcinoma cells to Carboplatin but is absent in Carboplatin-resistant cells

The major obstacle of successful tumor treatment with carboplatin (CBP) is the development of drug resistance. In the present study, we found that following treatment with CBP the amount of platinum which enters the human laryngeal carcinoma (HEp2)-derived CBP-resistant (7T) cells is reduced relative to the parental HEp2. As a consequence, the formation of reactive oxidative species (ROS) is reduced, the induction of endoplasmic reticulum (ER) stress is diminished, the amount of inter- and intrastrand cross-links is lower, and the induction of apoptosis is depressed. In HEp2 cells, ROS scavenger tempol, inhibitor of ER stress salubrinal, as well as gene silencing of ER stress marker CCAAT/enhancer-binding protein (CHOP) increases their survival and renders them as resistant to CBP as 7T cell subline but did not influence the survival of 7T cells. Our results suggest that in HEp2 cells CBP-induced ROS is a stimulus for ER stress. To the contrary, despite the ability of CBP to induce formation of ROS and activate ER stress in 7T cells, the cell death mechanism in 7T cells is independent of ROS induction and activation of ER stress. The novel signaling pathway of CBP-driven toxicity that was found in the HEp2 cell line, i.e. increased ROS formation and induction of ER stress, may be predictive for therapeutic response of epithelial cancer cells to CBP-based therapy.

Separation and cultivation of laryngeal carcinoma-associated fibroblasts and biological influence on a laryngeal carcinoma cell line

CONCLUSIONS

Carcinoma-associated fibroblasts (CAFs) can influence the biological characteristics of a laryngeal carcinoma cell line. These results could lay the foundation for further studies on the role of CAFs in the laryngeal tumor-host microenvironment.

OBJECTIVE

CAFs are important contributors to the microenvironment in determining the fate of tumors. The aim of this study was to separate, culture, and identify laryngeal CAFs and investigate their biological influence on the laryngeal carcinoma cell line.

METHODS

The primary CAFs and normal fibroblasts (NFs) of the larynx were obtained by tissue culture. The cells were verified according to immunohistochemical and immunofluorescence staining of certain proteins. Conditioned medium (CM) from CAFs and NFs was obtained. Functional assays were performed to test the influence of each CM on laryngeal carcinoma cell lines.

RESULTS

Third-passage purified laryngeal CAFs and NFs were successfully attained. The CAFs showed positive staining for vimentin, α-smooth muscle actin (α-SMA), and fibroblast activation protein (FAP). The migration ability of the CAFs increased significantly compared with that of NFs (p < 0.05). CM from CAFs (compared with CM from NFs) stimulated proliferation, migration, and invasion to a greater extent.

Long-term outcomes of supracricoid partial laryngectomy with cricohyoidoepiglottopexy and its modified version

OBJECTIVE

To investigate the long-term outcomes of supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP) and its modified version, in which we reserve the poster inferior borders of both thyroid cartilage laminas to protect swallowing function.

METHODS

This retrospective survival analysis was performed in 86 patients, wherein 46 undergoing CHEP and 40 undergoing modified CHEP. Their decannulation data were reviewed. We used swallowing quality-of-life questionnaire to measure the quality-of-life in 53 of the 65 survivals at the end of the follow-up period in 2011. Of the 53 patients, 24 underwent CHEP, while the remaining by modified CHEP.

RESULTS

The log rank test showed no significant difference in survival distributions of 2 the groups (p=0.92). The decannulation rate was 93.5% in CHEP and 100% in modified CHEP, showing no significant difference. The time span of decannulation in CHEP was 19.0+/-4.6 days, significantly longer than (14.0+/-2.3 days) the modified CHEP (p=0.000). As to quality-of life data, one-way multivariate analysis of variance, revealed a significant multivariate main effect for groups (p=0.001), and significant univariate main effects in 5 scales out of 11 (p<0.05), which showed a better swallowing life quality in modified CHEP.

CONCLUSION

There was no significant difference in survival rate between the 2 surgeries. The modified CHEP succeeded in earlier decannulation and better long-term swallowing life quality. Thus, modified CHEP is worth promoting, as long as indications were strictly conformed.

Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer

PURPOSE

To report the long-term results of the Intergroup Radiation Therapy Oncology Group 91-11 study evaluating the contribution of chemotherapy added to radiation therapy (RT) for larynx preservation.

PATIENTS AND METHODS

Patients with stage III or IV glottic or supraglottic squamous cell cancer were randomly assigned to induction cisplatin/fluorouracil (PF) followed by RT (control arm), concomitant cisplatin/RT, or RT alone. The composite end point of laryngectomy-free survival (LFS) was the primary end point.

RESULTS

Five hundred twenty patients were analyzed. Median follow-up for surviving patients is 10.8 years. Both chemotherapy regimens significantly improved LFS compared with RT alone (induction chemotherapy v RT alone: hazard ratio [HR], 0.75; 95% CI, 0.59 to 0.95; P = .02; concomitant chemotherapy v RT alone: HR, 0.78; 95% CI, 0.78 to 0.98; P = .03). Overall survival did not differ significantly, although there was a possibility of worse outcome with concomitant relative to induction chemotherapy (HR, 1.25; 95% CI, 0.98 to 1.61; P = .08). Concomitant cisplatin/RT significantly improved the larynx preservation rate over induction PF followed by RT (HR, 0.58; 95% CI, 0.37 to 0.89; P = .0050) and over RT alone (P < .001), whereas induction PF followed by RT was not better than treatment with RT alone (HR, 1.26; 95% CI, 0.88 to 1.82; P = .35). No difference in late effects was detected, but deaths not attributed to larynx cancer or treatment were higher with concomitant chemotherapy (30.8% v 20.8% with induction chemotherapy and 16.9% with RT alone).

CONCLUSION

These 10-year results show that induction PF followed by RT and concomitant cisplatin/RT show similar efficacy for the composite end point of LFS. Locoregional control and larynx preservation were significantly improved with concomitant cisplatin/RT compared with the induction arm or RT alone. New strategies that improve organ preservation and function with less morbidity are needed.

Infiltrative laryngeal lipoma in a Yorkshire Terrier as cause of severe dyspnoea

A 10-year-old Yorkshire Terrier with suspected laryngeal paralysis was referred for further examination and surgical treatment. The dog displayed severe dyspnoea and dysphonia. Ventrolateral to the larynx a soft-elastic mass of 2 cm diameter was palpated and confirmed by radiography. Histopathological examination of the resected mass revealed an infiltrative lipoma/lipoma. Although the dog totally recovered after surgery, the prognosis remains guarded due to the high risk of a recurrence. Tumours of the larynx in general and an infiltrative lipoma specifically should be added to the list of differential diagnosis in dogs presented with clinical signs that could be misinterpreted as laryngeal paralysis.

New modalities to treat laryngeal cancer

Early laryngeal cancer comprises T1 and T2 stages of the disease. Open functional operations achieve local control of the disease in 90-95% of T1 patients and in 70-90% of T2 patients. Primary RT achieves local control in 85-94% of T1 tumors and in 70-80% of patients with T2 tumors. Introduction of endoscopic laser surgery resulted in further popularization of preservation laryngeal surgery, whereby equally successful treatment results are achieved with minimal invasiveness. Quality of voice is also better after RT and laser resection. In the last century a golden standard of treatment of advanced laryngeal cancer (T3/T4 stage) was total laryngectomy (TL) with neck dissection followed by adjuvant RT. Overall 5 year survival was around 50%. Due to impact of TL on quality of life, "Larynx preservation strategy" (LPS) was developed in the early '90 for advanced stages of the disease. Novel approach is an introduction of targeted therapy, such as anti-EGFR monoclonal antibody, cetuximab. Concomitant cetuximab with RT achieves higher survival, and better locoregional disease control in comparison to administration of single RT modality. Therefore non-surgical methods of treatment of advanced laryngeal carcinoma are constantly changing and improving as new chemotherapeutics are being introduced into protocols. Uncritical enthusiasm with non-surgical methods of treatment resulted in higher incidence of treatment toxicities, higher rates of "salvage surgery" with more frequent adverse effects. That resulted in a consensus attempt around "LPS" project with reevaluation of clinical studies and uniform recommendations for future studies. When choosing appropriate therapy for oncological patient, quality of life (QOL) is a special category to be taken into account besides complications, pain, duration of treatment and overall benefit for the patient.

A fabricated forearm free flap with accompanying phonation tube for simultaneous reconstruction of a pharyngolaryngeal circumferential defect and voice loss: new surgical modification with functional phonation outcome

BACKGROUND

Total pharyngolaryngectomy is potentially ablative surgery, resulting in compromise of some most basic functions of life, including speech and swallowing. Tracheoesophageal puncture is the gold standard for voice restoration. But it still has prosthesis-related problems.

OBJECTIVES/HYPOTHESIS

We designed a uniquely customized radial forearm free flap (RFFF), which also incorporated a region for phonation tube (PT) creation, for the dual purpose of circumferential laryngopharyngeal defect reconstruction and voice production.

METHODS

From August 2005 to September 2010, there were 18 male patients with late-stage hypopharyngeal cancer (HPC) or laryngeal cancer (LC) who received one-stage reconstruction with the fabricated RFFF-accompanying PT after total pharyngolaryngectomy. We recorded the phonation outcome of phonation efficacy (PE) and maximal phonation time (MPT) postoperatively within 1 month and at least 1 year after surgery.

RESULTS

Nine patients suffered from HPC and the others suffered from LC. Twelve patients received concurrent chemoradiotherapy after surgery. The follow-up time was 12 to 56 months (mean 28.7 months). There was no significant variance in the PE (79.72%, SD=21.93% vs. 62.50%, SD=39.60%, respectively; p = 0.115) and MPT (2.58 seconds, SD=1.80 vs. 2.97 seconds, SD=3.96, respectively; p = 0.878) between the first and last follow-up points, even when the patients were grouped by radiotherapy status after surgery or by disease group.

CONCLUSIONS

The phonation outcome in our experience was satisfactory and it tolerated postoperative radiotherapy during at least the 12-month follow-up period.

[The function of lymphangiogenesis and the expression of Cathepsin D in laryngeal carcinoma metabasis]

OBJECTIVE

To study the function of lymphangiogenesis and the expression of Cathepsin D (Cath-D) in laryngeal carcinoma metabasis and clinical pathology character.

METHOD

The expression of Cath-D were detected in 76 laryngeal carcinoma with immunohistochemistry (SP method). Podoplanin was used as the marker of lympgatic vessel endotheliocytes to label lympgatic vessel in 76 laryngeal carcinoma,lymphatic microvessel density were measured,and the paraneoplastic tissues was used as control group.

RESULT

The positive rate of Cath-D in paraneoplastic tissue, laryngeal carcinoma and in pathology classification, in clinical stage, in cervicale lymphonode metastasis negative and positive group were significantly different. However, there had no difference between the positive rate of Cath-D in the age specific and clinical classification. c) The lymphatic microvessel density in paraneoplastic tissue, laryngeal carcinoma and clinical stage, in glottic carcinoma and supraglottic carcinoma, in cervical lymphonode metastasis negative and positive group were significantly different; but there had no difference in age-specific and pathology classification.

CONCLUSION

(1) The high expression of lymphatic microvessel density and the increasing expression of Cath-D could promote cervical lymphonode metastasis in aryngeal carcinoma. (2) There had a correlation between the high expression of lymphangiogenesis and Cath-D in laryngeal carcinoma, and had cooperation in aryngeal carcinoma lymphonode metastasis.

Material parameter computation for multi-layered vocal fold models

Today, the prevention and treatment of voice disorders is an ever-increasing health concern. Since many occupations rely on verbal communication, vocal health is necessary just to maintain one's livelihood. Commonly applied models to study vocal fold vibrations and air flow distributions are self sustained physical models of the larynx composed of artificial silicone vocal folds. Choosing appropriate mechanical parameters for these vocal fold models while considering simplifications due to manufacturing restrictions is difficult but crucial for achieving realistic behavior. In the present work, a combination of experimental and numerical approaches to compute material parameters for synthetic vocal fold models is presented. The material parameters are derived from deformation behaviors of excised human larynges. The resulting deformations are used as reference displacements for a tracking functional to be optimized. Material optimization was applied to three-dimensional vocal fold models based on isotropic and transverse-isotropic material laws, considering both a layered model with homogeneous material properties on each layer and an inhomogeneous model. The best results exhibited a transversal-isotropic inhomogeneous (i.e., not producible) model. For the homogeneous model (three layers), the transversal-isotropic material parameters were also computed for each layer yielding deformations similar to the measured human vocal fold deformations.

Functional outcomes and laryngectomy-free survival after transoral CO₂ laser microsurgery for stage 1 and 2 glottic carcinoma

OBJECTIVE

To compare the functional and oncologic outcomes of transoral CO₂ laser microsurgery relative to radiotherapy for early-stage glottic carcinoma.

DESIGN

Functional analysis: population-based, prospective, nonrandomized consecutive series of stage 1 and 2 glottic carcinoma treated with laser surgery (n  =  54) or radiotherapy (n  =  25). Oncologic analysis: population-based, historical cohort comparing laser surgery (n  =  54) and radiotherapy (n  =  76).

SETTING

Academic cancer centre.

METHODS AND OUTCOME MEASURES

Functional results were prospectively collected prior to treatment and at 3, 6, 12, and 24 months following treatment using validated performance scales assessing general level of function, speech, and swallowing. Oncologic results were collected from a larger cohort from the cancer registry of CancerCare MB.

RESULTS

Laser surgery resulted in a voice that was less likely to be understood all the time (Performance Status Scale for Head and Neck Cancer Patients: understandability score < 100; OR  =  12.2; p  =  .03) and a higher likelihood of having a Voice Handicap Index (VHI-10) score of 10 or more (OR  =  16.2; p  =  .001). Five-year laryngectomy-free survival rates for laser versus radiation were 87 versus 76% (p  =  .16). Subset analysis revealed that stage 1 5-year laryngeal preservation rates for laser (n  =  51) versus radiation (n  =  46) were 100 versus 86% (p  =  .02).

CONCLUSIONS

There is a higher likelihood of hoarseness after laser surgery, but the severity of this handicap is mild in most patients. Laser microsurgery results in excellent laryngeal preservation rates, which may exceed those of radiation.

[First experience with intrasurgical brachytherapy in the combined treatment for locally advanced laryngeal cancer]

Results of combined radiosurgical treatment with larynx preservation, and pre- and postoperative distant external irradiation, were evaluated. Forty-eight patients with locally advanced laryngeal cancer received single-step individually-tailored tissue application, followed by high-dose brachytherapy. Discriminative function of the larynx was restored in all patients within 2 days involving swallowing disturbances in 8%. Breathing function was restored in 98% within 2 days to 6 months after completion of treatment. Three-year relapse-free survival was 95.8%.

Influence of breathing resistance of heat and moisture exchangers on tracheal climate and breathing pattern in laryngectomized individuals

BACKGROUND

The aim of this study was to determine the influence of breathing resistance of heat and moisture exchangers (HMEs) on endotracheal climate and breathing pattern.

METHODS

Endotracheal temperature and humidity and tidal volumes were measured in 11 laryngectomized patients with a regularly used HME with "standard" breathing resistance (Provox Normal HME; R-HME), a low breathing-resistance HME (Provox HiFlow HME; L-HME), and without HME.

RESULTS

Both R-HME and L-HME increased end-inspiratory humidity (+5.8 and 4.7 mgH(2)O/L, respectively), decreased end-inspiratory temperature (-1.6 and -1.0 degrees C, respectively), and prolonged the exhalation breath length to approximately 0.5 seconds. The R-HME significantly enlarged tidal volumes (0.07 L; p < .05).

CONCLUSIONS

Both HMEs significantly improve tracheal climate. The R-HME has better moistening properties and a small but significant positive effect on tidal volume. Therefore, if the higher resistance is tolerated, the R-HME is the preferred pulmonary rehabilitation device. The L-HME is indicated if lower breathing resistance is required.

Mental health after laryngectomy and partial laryngectomy: a comparative study

Patients treated for laryngeal cancer are confronted daily with the effects of the operation. The choice of treatment method can have a significant impact on psychosocial adjustment. Three hundred and six out-patients who underwent surgical treatment for laryngeal cancer within the last two decades were interviewed in their own homes using the structured clinical interview for DSM-IV (SCID).Psychiatric disorders were diagnosed among 17.3% of the partial laryngectomy patients (PL) and 22.2% of the patients with total laryngectomy (LE). In comparing four variables (age, time elapsed since diagnosis, gender and subjective speech intelligibility), subjective speech intelligibility and age were the variables with a unique, significant effect on the frequency of psychiatric disorders, albeit only in the case of PL patients. The need for psychosocial rehabilitation for patients with partial laryngectomy tends to be underestimated. It is concluded that screening for psychological variables and subjective speech intelligibility can be beneficial for the identification of out-patients lacking appropriate treatment.

Structures constituting the sound source after the treatment of early glottic cancer

INTRODUCTION

We indicate the exclusive radiation therapy as initial approach for T1a glottic tumors, and the frontolateral laryngectomy for the tumors staged as T1b and selected T2 glottic tumors. The videolaryngostroboscopy is a useful tool to analyze the laryngeal structural changes and compensatory motion after the therapeutic approach.

OBJECTIVES

To evaluate the endolaryngeal structures of patients who participate in the vibratory sound source after the early glottic cancer treatment through the videolaryngostroboscopy.

METHODS

It was a retrospective transversal study in which 20 patients who underwent exclusive radiation therapy and 25 patients who underwent frontolateral laryngectomy were analyzed by means of videolaryngostroboscopy. The radiation doses ranged from 5000 to 7020 cGy in the radiation therapy group. The mucosal wave and the vibratory source components were evaluated.

RESULTS

All of the irradiated patients presented vibratory behavior, and hyperfunction was occasionally observed in four cases. The mucosal wave source was glottic in 18 cases and mixed in two cases. In the laryngectomy group, 10 supraglottic sources, 10 glottic sources, and five mixed sources were identified. Among the 10 cases of supraglottic source, eight patients presented global constriction and two patients presented medial constriction. Among the five cases of mixed source, two patients presented global constriction, one patient presented medial constriction, and one patient presented anteroposterior constriction. Regarding the number of anatomical structures presenting vibratory pattern, five patients had two structures, four patients had three structures, and one patient had four structures.

CONCLUSION

Patients who underwent radiation therapy recruit less supraglottic structures as vibratory source than the patients undergoing vertical laryngectomy.

[Assessment of speech quality in patients with resected larynx]

The organ salving treatment of laryngeal neoplasms including their surgical resection at one of the stages was given to 25 patients. They were further followed up for the assessment of vocal function. Analysis of speech was performed by a group of 5 auditors. They counted how many times each patient heard a consonant as a sonant and vice versa. Based on the analysis of mistakes, the patients were divided into the following three groups: group 1 (many mistakes), group 2 (moderate number of mistakes), an group 3 (practically no mistakes). The most common mistake was devocalization of voiced sounds. Postoperative analysis of speech quality characteristics revealed their dependence on the extent of surgical intervention, the presence of tracheostoma, the type of plastic correction, and the dose of radiation therapy. It was shown that extensive and combined frontal-lateral resection leads to voice impairment. Tracheostoma also have negative effect on speech discrimination.

Is a line the same as a box? Speech assessment by VAS is not superior to Likert scales in laryngeal cancer patients

BACKGROUND

The primary purpose was to assess if VAS or Likert was relatively more suitable when assessing self-ratings of voice and speech in patients treated for laryngeal cancer. An additional purpose was to investigate whether the scales differed in measuring change after treatment.

MATERIAL/METHODS

Using both VAS and Likert, 71 patients answered three questions at baseline and 12 months after treatment began. For test-retest analyses, additional data were used from 21 subjects. Non-parametric statistical methods suitable for comparing scales with different numbers of response alternatives were applied.

RESULTS

Test-retest reliability was strongest for the Likert scale. From baseline to follow-up, both scales detected significant improvements. However, for some Likert scores the associated VAS values varied across a wide range, and this was true for assessments at baseline, at follow-up, and for score changes. At baseline the inter-scale concordance showed a greater number of disordered pairs than at follow-up and on both occasions the older group produced a greater number of disordered pairs.

CONCLUSIONS

No support for the superiority of VAS over Likert was found. However, VAS may produce instability in response patterns. When using self-ratings of voice and speech to identify a need of further rehabilitation, Likert scales seem better suited.

Nutritional status in head and neck cancer patients

OBJECTIVE

Patients suffering from cancer of head and neck are at risk of nutritional depletion. The aim of our study was to investigate the role of type, location and stage of tumors in nutritional status.

PATIENTS AND METHODS

A population of 230 consecutive patients with head and neck cancer was enrolled. A nutritional evaluation was realized.

RESULTS

The distribution of tumour sites was: oral cavity (77 patients), pharynx (30 patients) and larynx (123 patients). Subjective Global Assessment (SGA) test showed significant differences. Midly malnourished frequency is higher in larynx site than others. Severely malnourished is higher in larynx and oral cavity than pharynx. In pharynx, larynx and oral cavity tumours is more frequent to be well nourished than severely malnourished. In pharynx and larynx tumours is more frequent to be mildly malnourished than severely malnourished. In stages II, III and IV are more frequent to be well nourished than severely malnourished and in stages II and III is more frequent to be mildly malnourished than severely malnourished.

CONCLUSIONS

SGA test shows a good nutritional status in patients with head and neck tumours. However, SGA test shows statistical differences in some categories of tumours stages or sites.

Developments in pathogenesis and diagnosis of gastroesophageal reflux disease

PURPOSE OF REVIEW

Although gastroesophageal reflux is a common disorder, diagnosis is still imprecise. Moreover, its pathogenesis is incompletely understood. This review summarizes recent progress in diagnosis and our understanding of the pathogenesis of gastroesophageal reflux disease.

RECENT FINDINGS

Recent studies have focused on the pattern of reflux in the distal esophagus, just above the esophago-gastric junction, challenging its importance on the genesis of reflux symptoms. New techniques, such as impedance, could improve the diagnostic yield, especially in patients with nonacid reflux. Esophageal sensitivity and motility, transient lower esophageal sphincter relaxations, and hiatus hernia are important pathogenic mechanisms of reflux disease. Studies showed that obesity plays a role in the pathogenesis of reflux symptoms; a disruption of the esophago-gastric junction (leading to hiatus hernia) could allow reflux to occur. The association between reflux (particularly nonacid) and extraesophageal manifestations of gastroesophageal reflux disease has been further evaluated.

SUMMARY

Improvement of diagnostic techniques and better understanding of the pathogenesis of reflux may lead to new or better therapeutic modalities. Our understanding of some of the risk factors for reflux has been increased. Extra-esophageal manifestations and their association with gastroesophageal reflux are still a very controversial and promising area of research.

The expression of Bcl-2 family proteins and spontaneous apoptosis in laryngeal carcinomas

Bcl-2 family proteins play an important role in the growth and biological behavior of tumors. This study aimed to determine Bcl-2 family proteins in laryngeal carcinoma and to examine their relationship with spontaneous apoptosis. The material studied was from 39 patients with laryngeal carcinoma. It was found that the expression of both Bak and Bax was lower in tumor tissues than in nontumor tissues. However, there was no difference in the expression of Bcl-2 between tumor and nontumor tissues. The frequency of spontaneous apoptosis was lower in tumor tissues than in nontumor tissues but was not significantly related to the expression of Bak, Bax, or Bcl-2. Bak was decreased in moderately differentiated tumors compared to well-differentiated tumors. In contrast to Bak, the expression of Bcl-2 was increased in moderately differentiated tumors compared to well-differentiated tumors. These results indicate that the reduction in Bak may be associated with an increase in tumor grade and dedifferentiation in laryngeal carcinomas. The lack of correlation between apoptosis and the expression of Bcl-2 family proteins suggests that spontaneous apoptosis in laryngeal carcinoma is a complex process and that molecules other than Bak, Bax, and Bcl-2 participate in it.

Voice in early glottic cancer compared to benign voice pathology

The purpose of this study is to compare (Dutch) Voice Handicap Index (VHIvumc) scores from a selected group of patients with voice problems after treatment for early glottic cancer with patients with benign voice disorders and subjects from the normal population. The study included a group of 35 patients with voice problems after treatment for early glottic cancer and a group of 197 patients with benign voice disorders. Furthermore, VHI scores were collected from 123 subjects randomly chosen from the normal population. VHI reliability was high with high internal consistency and test-retest stability. VHI scores of glottic cancer patients were similar to those of patients with voice problems due to benign lesions. Both groups of patients were clearly deviant from the normal population. Within the normal population, 16% appeared to have not-normal voices. Based on ROC curves a cut-off score of 15 points was defined to identify patients with voice problems in daily life. A clinical relevant difference score of 10 points was defined to be used for individual patients and of 15 points to be used in study designs with groups. Patients with voice problems after treatment for early glottic cancer encounter the same amount of problems in daily life as the other voice-impaired patients. The VHI proved to be an adequate tool for baseline and effectiveness measurement of voice.

Longstanding recurrent laryngeal papillomatosis: impact on voice quality

Human papilloma virus (HPV) infection in the larynx often requires frequent surgical procedures in order to keep voice quality reasonable. The purpose of this study was to evaluate the speaking voice quality of patients with longstanding recurrent laryngeal papillomatosis (RLP). The patients were seven males with adult-onset RLP whose disease had lasted over 5 years, and who were free of papilloma at the time of examination. Each patient had an age- and gender-matched control with similar smoking habits. Voice samples were recorded and acoustic analysis as well as perceptual listening test were performed. In our series a perceptual test discriminates between normal and pathological voice quality more precisely than acoustical voice analysis. It appears that the voice of the papilloma patient, even after frequent phonosurgical operations, is not deviant from the normal when analyzed acoustically, but perceptual assessment shows that overall quality is less than optimal, and roughness and breathiness are increased.

[Reestablishment of the vocal function in patients with pharyngospasm after laryngectomy for laryngeal cancer]

Tracheoesophageal bypass was made in 114 patients after laryngectomy for reestablishment of voice. Of them, 17 (14.4%) patients had pharyngospasm which hinders voice recovery. To prevent this complication, the authors propose a special surgical policy which is different for delayed and primary (intraoperative) prosthesis.

Vocal Outcomes After Laser Resection of Early-Stage Glottic Cancer With Adjuvant Cryotherapy

OBJECTIVE

To evaluate the vocal outcomes of patients with early-stage glottic carcinoma undergoing laser resection with adjuvant cryoablative therapy.

DESIGN

Retrospective review.

SETTING

Tertiary care center. Patients Twenty patients with early-stage glottic carcinoma. Intervention Treatment of early-stage glottic carcinoma with endoscopic carbon dioxide laser resection in conjunction with cryoablation.

MAIN OUTCOME MEASURES

Disease-free survival and subjective and objective measures of posttreatment voice quality, based on serial videolaryngostroboscopy.

RESULTS

There was 1 local treatment failure, with an overall mean disease-free follow-up of 32.6 months (range, 3-93 months). Carbon dioxide laser resection and cryoablative therapy were associated with a significant improvement in subjective voice quality (P<.001). Long-term dysphonia was uniformly improved vis-à-vis the pretreatment condition, even among patients with the most advanced disease undergoing the widest resections. Posttreatment web formation was not noted among 4 patients with anterior commissure involvement.

CONCLUSIONS

Endoscopic laser laryngeal surgery performed in conjunction with cryotherapy for early-stage glottic carcinoma yielded excellent primary site control, while improving subjective and objective measures of voice quality. Combined laser surgery and cryotherapy is a possible alternative to radiotherapy for selected patients with early-stage glottic carcinoma who desire curative therapy, while optimizing vocal outcomes.

Electromyography of the cricoarytenoid unit during supracricoid laryngectomy with a cricohyoidoepiglottopexy procedure

Two patients who received supracricoid laryngectomy with cricohyoidoepiglottopexy to treat laryngeal cancers, underwent intra-operative electromyography analysis. After the lesion was removed and the electrodes were inserted into the remaining intrinsic laryngeal muscles, the depth of anaesthesia was carefully reduced. Gentle tactile stimulations were applied to the pharynx to trigger the reflex movement of the remaining arytenoids. Recordings were made when reflex movement was achieved.

Case one: Electromyography (EMG) of the remaining arytenoid demonstrated clear phase differences indicating reciprocal activities between the adductor group (lateral cricoarytenoid muscle, interarytenoid muscle) and the abductor muscle (posterior cricoarytenoid muscle). Case two: EMG of the remaining arytenoid demonstrated reciprocal activities between the interarytenoid muscle and the posterior cricoarytenoid muscle. Activity of the lateral cricoarytenoid muscle was not evident because the muscle was excised during removal of the paraglottic space. Mobility of the arytenoid was attributed to interaction between the interarytenoid muscle and posterior cricoarytenoid muscle. Reciprocal interaction between the interarytenoid muscle and posterior cricoarytenoid muscle alone is also capable of maintaining post-operative laryngeal functions after supracricoid laryngectomy with cricohyoidoepiglottopexy.

Validation of a voice prosthesis questionnaire to assess valved speech and its related issues in patients following total laryngectomy

OBJECTIVES

To establish the reliability and validity of a new self-administered questionnaire to assess valved speech and its related issues in patients who have undergone a total laryngectomy operation.

DESIGN

Cross-sectional psychometric validation study.

SETTING

Tertiary cancer care centre.

PATIENTS

We identified sixty-one total laryngectomy patients with no sign of recurrent disease and using voice prosthesis from the speech and language therapy database of the Royal Marsden Hospital. The patients were assessed using a postal self-administered voice prosthesis questionnaire concerning the voice valve and it's related issues. Patients were also asked to complete the University of Michigan voice related quality of life and University of Washington head and neck quality of life (version 4) questionnaires.

MAIN OUTCOME MEASURES

Test-retest and internal consistency reliability; content; criterion and construct validity.

RESULTS

We received completed questionnaires from fifty-one of the sixty-one total laryngectomy patients identified for the study providing a response rate of 84%. The median age of the group was 65 years (range: 40-85) with thirty-seven males and fourteen females. The internal consistency reliability using the Cronbach's alpha coefficient was 0.87 (range: 0.85 to 0.89). Test-retest reliability showed that more than 75% of patients had a score on re-test that was within 1 point of their original score. Content validity was ensured during the design process. The median Spearman correlation coefficient was 0.25 for convergent construct validity with the University of Washington head and neck quality of life questionnaire and 0.64 for criterion validity on comparison with the University of Michigan voice related quality of life scale.

CONCLUSIONS

The voice prosthesis questionnaire is the first validated and reliable self-administered questionnaire designed specifically for evaluating valved speech and its related issues in patients who have undergone total laryngectomy. The voice prosthesis questionnaire has significant utility for audit, outcomes research and monitoring in this unique group of patients.

Laryngeal preservation in head and neck cancer: multidisciplinary approach

Since the first total laryngectomy was undertaken, efforts have been made to avoid removing the entire larynx. For a long time, partial surgery and radiotherapy were the only options that could preserve the larynx. Development of active chemotherapy regimens has prompted an era of intensive clinical research. Induction chemotherapy followed by radiotherapy in patients with objective responses has been shown to allow conservation of the larynx in nearly two-thirds of individuals, without any effect on survival; concurrent chemoradiotherapy also provides high rates of laryngeal preservation, again without affecting survival; and induction chemotherapy followed by concurrent chemoradiotherapy is under investigation. In the meantime, partial open surgery and endoscopic carbon dioxide laser procedures are feasible in selected moderately advanced laryngopharyngeal cancers as an alternative to destructive surgery. Altered fractionation radiotherapy can also be used in management of these tumours, and targeted treatments have opened a new area of clinical research. Findings of basic research and modern imaging should provide useful approaches for selection of patients for various strategies.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.